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1 Literature
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14. Sideri M, Jones RW, Wilkinson EJ, Preti M, Heller DS, Scurry J, Haefner H, Neill S.Squamous
vulvar intraepithelial neoplasia. 2004 Modied terminology, ISSVD Vulvar Oncology
Subcommitee. J Reprod Med. 2005;50:807–10.
15. Faro S.Infections of the vulva, vagina, and cervix. In: Kovac SR, Zimmermann CW, edi-
tors. Advances in reconstructive vaginal surgery, vol. 2007. Philadelphia: Wolters Kluwer/
Lippincott Williams & Wilkins; 2007. p.383–96.
16. Stenchever MA, Mishell D, Herbst A. Infections of the lower genital tract. Comprehensive
gynecology. St Louis: Mosby; 2001. p.482–6.
17. O’Dey DM, Bozkurt A, Pallua N. The anterior Obturator Artery Perforator (aOAP) ap:
surgical anatomy and application of a method for vulvar reconstruction. Gynecol Oncol.
2010;119:526–30. Epub 2010 Sep 24.
18. O’Dey DM.Die rituelle Beschneidung der Klitorisregion: Anatomie und Wiederherstellung
mittels Omega-Domed ap. Plast Chir. 2014;14(1):44–7.
19. O’Dey DM.Complex reconstruction of the vulva following female genital mutilation/cutting.
Urologe. 2017;56(10):1298–301.
20. Johnson C, Nour NM.Surgical techniques: debulation of Type III female genital cutting. J
Sex Med. 2007;4:1544–7.
21. Seifeldin A.Genital reconstruction surgery after female genital mutilation. Obstet Gynecol Int
J. 2016;4(6):00129. https://doi.org/10.15406/ogij.201604.00129.
22. Madzou S, Ouédraogo CMR, Gillard P, Lefebvre-Lacoeuille C, Catala L, Sentilhes L,
Descamps P. Chirurgie plastique reconstructice du clitoris après mutilations sexuelles. Ann
Chir Plast Esthet. 2001;56:59–64.
23. O’Dey DM. Rekonstruktion nach ritueller Beschneidung. Deutsche Hebammenzeitschrift.
2014;12:51–4.
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Basic Consideration
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2.1 Clinical Setting
An optimal clinical setting for complex vulvar reconstruction should meet the
requirements necessary for inpatient treatment. The facility must be specialized and
well equipped, with well-qualied and motivated staff members, because therapy of
FGM/C patients needs professionalism, accuracy, and passion. The facility should
offer a pleasant examination room with a changing area, so that the patient can feel
comfortable. Furthermore, a system to perform standardized photography should be
available. Photographs, of course, are especially necessary to document the preoperative and postoperative status. The ofce-photography arrangement should provide two frontal light units for uniform illumination and a simple homogeneous
background for increased contrast and reduced distraction to get photographs in the
upright position (Fig.2.1a). An examination chair should also be provided for ofce
photography (Fig. 2.1b). Basic viewpoints include frontal (Fig. 2.1c) and back
(Fig.2.1d) while standing, as well as frontal with the vulva at rest (Fig.2.1e) as well
as the vulva slightly tightened (Fig.2.1f) in the supine position with angled legs or
the lithotomy position, respectively. The patient must be informed of and consent to
the purpose of medical use of the photographs as well as electronic archiving of the
personal data.
The surgeon requires in-depth understanding of anatomy of the female genital,
and must be condent with the topography, and techniques of dissection under normal and changed anatomic conditions. The responsible surgeon with the help of a
preferable female assistant should almost always perform the examination. In addition, a representative with translational skills or a translator should attend the examination from a separate area or at least attend the nal talk. It should be guaranteed
that the patient is overall informed about the prevailing anatomic condition, intended
reconstruction, expectable improvement resulting from the operation, need for temporary bladder catheterization, postoperative care, delayed restart of sexual activity,
temporary incapacity for work, and some more.
2
© Springer Nature Switzerland AG 2019
D. m. O´Dey, Vulvar Reconstruction Following Female Genital Mutilation/
Cutting (FGM/C) and other Acquired Deformities,
https://doi.org/10.1007/978-3-030-02168-9_2
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a b
2 Basic Consideration
Fig. 2.1 Ofce photography. (a) (top left) Upright photography with a simple single-colored
background. (b) (top right) Chair with angled legs for examination and photography. (c) (middle
left) Standard upright position frontal view in a 27-year-old FGM/C III patient. (d) (middle right)
Same patient standard upright position in back view (in cases following or scheduled for full vulvar reconstruction). (e) (bottom left) Same patient standard lithotomy position vulva at rest. (f)
(bottom right) Same patient standard lithotomy position with the vulva slightly tightened up giving
view to the vaginal introitus
2.2 Patient Management
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ef
Fig. 2.1 (continued)
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2.2 Patient Management
The vulva is a unique anatomic region and has a special signicance for each individual. Concerning examination, the physician requires both an appropriate handling of and empathy for the patient. A profound review of the history is critical.
FGM patients frequently do not dare to describe their problems clearly because they
culturally used to not complain. On request, however, patients especially describe
the occurrence of pain during menstruation, and sexual intercourse, as well as the
absence of sexual sensation, and some more. In some patients inspection might be
more appropriately performed in the operating room with the patient sedated or
asleep. It is self-evident that every examination no matter where must be performed
in consent with the patient. As mentioned above it is usually benecial to have a
representative accompanying the patient. It is important to nd out what was done
before. Interview, inspection, and palpation, therefore, are critical in examining the
outer female genital. Inspection leads into an analytic overview of the underlying
problem and the necessary reconstructive needs. The examiner gets an impression
about the aOAP-ap harvest side at the thigh creases lateral to the vulva, pubic hair
important for ap design or adjunctive procedures like epilation, and which parts of
the vulva can be included in the reconstructive plan. It’s enormous which information you get from adherence or sliding capacity of the overlying tissue or a scar to
the underlying layers. Palpation of the inferior pubic ramus and the medial border
of the obturator foramen half the way from the pubic body to the ischial tuberosity
determine the aOAP vessel. Furthermore, palpation of the tissue overlying the symphysis brings information about the position of the remaining clitoral organ,
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2 Basic Consideration
existence of a clitoral cyst, or the symmetry pattern of the remaining skin. All the
ndings must then be correlated with the operative plan.
Patient management does further include optimizing operative and postoperative
conditions. Preoperative mechanical bowel preparation using light magnesium oxide
with citric acid and postoperative control of defecation should avoid contamination of
the suture lines likewise reducing the risk of infection, wound-healing disorders, or ap
lost. In addition, prophylactic antibiotics are administered intravenously on the day of
surgery (Table2.1) and up to two days after, followed by oral application for further 5
to 7 days postoperativelydepending on the circumstances; painkillers and decongestive medication are applied for 5–8days. In addition, some cases may prot from oral
or systemic application of cortisone to reduce inammatory response and swelling.
Especially in obese patients pressure relief at the ap site especially in region of the
posterior commissure through angled legs on pillows in the supine position combined
with pressure-reduced bedding is benecial for 3–5days until complete ap autonomy and reliable load capacity should have been achieved. During that time the patient
is advised to stay in bed for 2days postoperatively. I use to mobilize my patients out
of bed on day 3 after surgery. Beforehand careful physiotherapy is performed in bed
without impairing the operative result. The patient is further instructed in the use of
the recommended ointments. The latter include an antibiotic ointment for outer suture
lines, estrogen ointment for the region of the clitoris and the vaginal introitus, and
heparin ointment in case of discoloration caused by supercial hematomas.
2.3 Clinical Management
FGM/C is a sensitive issue and patients are also. Clinical management, therefore, is
complex. Once infrastructure is formed and specialized protocols have been well
established, clinical management becomes easier. Beforehand, however, education
is obligatory. All the staff members and nurses must be profoundly briefed about
FGM/C itself. They should know about what generally happened to the patients,
what kind of deformities exist, the need and importance of reconstructive surgery,
the potential of reconstructive surgery, the advantage of up-to-date reconstructive
procedures, and especially the postoperative care necessary to carry the patients to
an overall successful result. This also includes empathy for cultural background of
the patients. Sometimes FGM/C patients do not only feel satisfaction after surgery,
but also undergo ashbacks of their childhood; that means ashbacks of FGM/C.It
is therefore important to sensitize employees about possible psychological distress
of the patients that should never ever be trivialized. Psychological adjunctive therapy therefore is an important option and sometimes necessary, but need to be
Table 2.1 Prophylactic antibioticsfollowing vulvar reconstruction
Antibiotic
Clindamycin 0.6 1-1-1
Cefuroxime 1.5 1-1-1
Metronidazole 0.5 1-0-1
Concentration [g]
Application (intravenous)
2.4 Anatomy
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decided in the individual case. Confronting each patient with psychological help
will not nd generally acceptance and is moreover not necessary. However, psychological help should not be underestimated especially in those patients unspecically
searching for help. FGM/C patients nding my ofce usually had had professional
or unprofessional psychological support beforehand; it depends individually on
whether such support should be continued or not. The will for reconstruction is usually strong in most of my patients, and the postoperative gain of form and function
does not usually cause psychological instability but the very opposite.
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2.4 Anatomy
All the following anatomic orientations refer to the dorsal lithotomy position and
are modeled after standardized descriptions of the female genital. Anterior directs
toward the mons pubis, and posterior directs toward the anus. Inferior means
directed to the surgeon sitting in front of the patient. Superior directs toward the
promontory of the sacrum. Lateral and medial depend on the sagittal plane, which
divides the pelvic bone into halvesin the superior-inferior view.
Anatomic descriptions given in the following are oriented toward the reconstructive needs and do not intend to give an overall overview of the female genital and
bordering regions. Generally, the region anterior to the anus bordered by inferior
rami of the pubic bones and the symphysis is called the urogenital region. Within
that region the pudendal region comprises the outer female genital. The region
below the urogenital region is called the anal region. The connecting region between
the urogenital region and the anal region is called the perineum [1].
2.4.1 Region oftheClitoris
Personal anatomic dissections are highly recommended to train and improve the
own surgical understanding and skills. Especially altered topographic conditions
forced by former interventions such as genital mutilations assume that the surgeon
is condent with the regular anatomy (Fig.2.2). Besides morphologic conditions
knowledge of vascular anatomy is imperative (Fig.2.2b).
Anatomy of the clitoris is complex [2]. Interactive sexual function of the clitoral
region including the clitoral organ (crura, body, glans), bulbs, distal urethra, and
inferior vagina seems to be till date somewhat unclear [3, 4, 5]. The whole region
seems to be in sum responsible for sexual function and orgasm [3]. The clitoral
organ consists of an inner hidden and an outer visible part. The inner part is formed
by the clitoral crura whereas the clitoral body terminated by the clitoral glans forms
the outer part. The crura run parallel to the ischiopubic ramus while further advancing to the pubic symphysis to merge into the clitoral body [4, 5]. The clitoral crura
thereby are geniculately curved and change their upward direction into a downward
course of the clitoral bodies (Fig.2.3a–f). The clitoral bodies are xed to the symphysis by the suspensory ligament consisting of a supercial and a deep part [3, 6].
Due to their retraction force, both components of the suspensory ligament must be
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2 Basic Consideration
a
b
Fig. 2.2 Setting for anatomic dissections. (a) (top) Usual dorsal positioning of the corpse for
anatomic dissection of the vulvar and inguinal region. (b) (bottom) Secondary vessel injection
technique for further dissection of the vascular tree
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2.4 Anatomy
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Anatomic dissection detailing region of the clitoris in a 76-year-old corpse. (a) (top left)
Fig. 2.3
View of the outer female genital prior to dissection. (b) (top right) Anterior view of the clitoral
organ after en bloc dissection with the clitoral tip and clitoral bodies as well as the supercial part
of the suspensory ligament. (c) (middle left) Anterior view of the supercial part of the suspensory
ligament (clamp) following separation from the clitoral organ. (d) (middle right) Lateral view
showing the clitoral tip, clitoral bodies, and clitoral crura freed from the supercial and deep part
of the suspensory ligament. (e) (bottom left) Ventral view of the clitoral organ; topography of the
aOAP-perforator vessel close to the clitoral crura (marked with a yellow background on the left
side, lateral to the inferior ramus of the pubic bone). (f) (bottom right) Dorsal view of the clitoral
organ; topography of the clitoral nerves (marked with a yellow background) next to the clitoral
artery and accompanying veins
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Fig. 2.3 (continued)
2 Basic Consideration
Fig. 2.4 Normally congured vulva of a 19-year-old woman. (a) (left) The normally congured
vulva comprises (description from inside to outside): the vestibule in front of the hymen and the
vaginal introitus being covered and anked by the minor labias laterally, the clitoral tip anteriorly,
and the perineum posteriorly; the minor labias are continued by the frenulum (roots of the minor
labias) anteriorly followed by the clitoral prepuce; the major labias border the minor labias laterally. (b) (right) The normally congured vulva under slight lateral tension opening the vulvar
vestibule
2.4 Anatomy
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cut to the bone when mobilizing the retracted and straightened clitoral bodies during reconstruction (Fig.2.3c, d). The clitoral bodies coalesce and terminate in the
clitoral glans (Fig.2.3b). That’s why the clitoral bodies are almost always involved
within the ritual of clitoral cutting.
In the normally congured, unimpaired vulva (Fig.2.4) the clitoral prepuce covers both the visible part of the clitoris that means the clitoral glans and the upper
invisible part that means the clitoral bodies. The posterior prepuce covering the
clitoral glans thereby forms a hood, whereas the anterior part forms an anteriorly
fading wall. The lower part of the prepuce merges into the minor labia, called “roots
of the minor labias” (frenulum clitoridis). The split roots of the minor labias border
the clitoral tip. The hoof-shaped space between the prepuce and the clitoral glans is
called the coronary sulcus of the glans [1].
The pudendal plexus, originating from the second to fourth sacral segment of the
spinal cord, is responsible for sensory supply of the clitoris [3, 5]. Branches course
through the infrapiriform foramen directed to the symphysis. In region of the symphysis they form the dorsal clitoral branches innervating both the clitoral body and
the clitoral glans (Fig.2.3f). They travel along the upper surface of the clitoral body
in the 11 and 1 o’clock positions [4] to nally enter the clitoral glans [3]. Within the
glans both nerves spread into their terminal branches.
In FGM/C patients stumps of the clitoral nerves anking the stump of the clitoral
bodies need to be neurolysed microsurgically to make them eligible for successful
reinnervation of the newly formed clitoral tip. That means that they need to be cut
on a level showing healthy normally structured tissue. Detected neuromas, brous
tissue, and scars must be excised.
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2.4.2 Region oftheMinor andMajor Labias
Normal anatomy of the vulva is complex and unique (Fig.2.4). The usually bulgy
major labias border the pudendal column (rima pudenda), start at the anterior commissure, and end at the posterior commissure localized at the anterior border of the
perineum. They contain fatty tissue traversed by a loose network of connective tissue bands. They show all over sebaceous as well as sweat glands and hair growth as
part of the pubic hair. Between the major and the minor labias the interlabial sulcus
is formed fading at the anterior and posterior commissure [1].
The minor labias run from the clitoral frenulum downward and mostly disappear
on the level of the lower third of the anking major labias or end within the frenulum labiorum pudendi at the posterior commissure. Due to the lacking fat layer, the
minor labias are very narrow, lled with connective tissue showing sebaceous
glands, and a rich vasculature including numerous veins. They do clearly vary in
size and texture [7]. The opening between the minor labias is known as the vestibule. Within the vestibule and below the clitoral tip opens the external orice of the
urethra. Further posteriorly and dorsally follows the hymen traversing the vaginal
introitus. The bulbi vestibuli are located both sides to the vaginal introitus covered
by the bulbo-cavernosi muscle (Fig.2.5). The bulbo-cavernosi muscle therefore
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